1
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van den Beukel BAW, Poot A, Beuk R. Fatal Course of Cutaneous Cholesterol Embolization Syndrome: A Case Report. INT J LOW EXTR WOUND 2023; 22:753-758. [PMID: 34791924 DOI: 10.1177/15347346211058590] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Cholesterol embolization syndrome is an increasing but underestimated problem after endovascular intervention or after the start of thrombolytic therapies. Embolies from the aortic wall involves abdominal organs and the skin of the lower extremities or buttocks. In our case a progressive ulceration and necroses occurs spontaneously. Endovascular treatment of the lower extremities was successful for a short period. Due to the progression of necrosis, both legs were amputated. Biopsies were taken from the skin were initially no directions to the diagnosis of Cholesterol embolization syndrome. After a second elliptical excision biopsy the diagnosis of cholesterol embolization syndrome was confirmed. Because the rapid progression of skin necroses despite the treatment of prednisone, patient died due to sepsis and renal failure. This case shows when arterial revascularization is performed and progression in skin necrosis occurs despite optimal arterial vascular status the diagnosis CES should be considered and treated in an early state of disease.
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Affiliation(s)
| | - A Poot
- Medisch Spectrum Twente, Netherlands
| | - R Beuk
- Medisch Spectrum Twente, Netherlands
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2
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Atheroembolic renal disease associated with dabigatran overdose. J Nephrol 2021; 35:1053-1057. [PMID: 34727351 DOI: 10.1007/s40620-021-01158-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 09/17/2021] [Indexed: 10/19/2022]
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3
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Dumas M, Flipo R, Blum L, Jouzel C, Brochériou I, Begon E. [Cholesterol crystal embolism mimicking a DRESS]. Rev Med Interne 2020; 41:275-278. [PMID: 32089328 DOI: 10.1016/j.revmed.2020.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 01/20/2020] [Accepted: 01/26/2020] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Clinical presentation of cholesterol crystal embolism (CCE) can be dermatologic when cholesterol crystals become lodged in small cutaneous arteries resulting in ischemia. We report a case of CCE with erythroderma misleading to a diagnostic of drug reaction with eosinophilia and systemic symptoms (DRESS). CASE REPORT A 66 year-old woman presented with erythroderma few months after initiation of allopurinol. Acute renal failure was present with elevation in plasma creatinine concentration (523μmol/L) and hypereosinophilia (HE) (5666/mm3). Finally, the REGISCAR score helped to rule out DRESS diagnostic. Past blood-count tests were analyzed revealing chronic HE present before allopurinol initiation. Renal biopsy identified CCE. CONCLUSION This case is the first to report a DRESS like presentation of CCE. Clinical findings are secondary to HE and not to occlusion of cutaneous arteries.
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Affiliation(s)
- M Dumas
- Service de dermatologie, hôpital René Dubos-Pontoise, 6, avenue de l'île de France, 95300 Pontoise, France.
| | - R Flipo
- Service de dermatologie, hôpital René Dubos-Pontoise, 6, avenue de l'île de France, 95300 Pontoise, France
| | - L Blum
- Service de dermatologie, hôpital René Dubos-Pontoise, 6, avenue de l'île de France, 95300 Pontoise, France
| | - C Jouzel
- Service de néphrologie, hôpital René Dubos-Pontoise, 6, avenue de l'île de France, 95300 Pontoise, France
| | - I Brochériou
- Service d'anatomie et cytologie pathologiques, hôpital universitaire Pitié-Salpêtrière, Sorbonne université, 47-83, boulevard de l'hôpital, 75013 Paris, France
| | - E Begon
- Service de dermatologie, hôpital René Dubos-Pontoise, 6, avenue de l'île de France, 95300 Pontoise, France
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4
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Shibata J, Yoshihara M, Kato T. Gastric remnant necrosis secondary to cholesterol crystal embolization after distal gastrectomy in a gastric cancer patient: a case report. BMC Surg 2020; 20:54. [PMID: 32192489 PMCID: PMC7082983 DOI: 10.1186/s12893-020-00716-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 03/13/2020] [Indexed: 11/10/2022] Open
Abstract
Background Distal gastrectomy with lymph node dissection, a standard operative technique for gastric cancer treatment, is safely performed because the stomach has a rich vascular supply. Gastric remnant necrosis caused by cholesterol crystal embolization following distal gastrectomy has not been described previously. We report a case of gastric remnant necrosis in a patient with cholesterol crystal embolization. Case presentation A 70-year-old man with a history of cholesterol crystal embolization presented to our surgery department with complaints of anorexia and dysphasia. He was diagnosed with gastric cancer invading the pyloric antrum and underwent distal gastrectomy with Billroth 2 reconstruction. On postoperative day 11, he developed abdominal pain without fever. Emergency laparotomy revealed that most parts of the remnant stomach were necrosed. Total gastrectomy with Roux-en-Y reconstruction and abscess drainage were performed. After surgery, anastomotic leakage occurred and was treated conservatively. However, the superior pancreaticoduodenal artery aneurysm suddenly ruptured and he expired. Conclusions Gastric remnant necrosis after distal gastrectomy can be a gastrointestinal presentation of cholesterol crystal embolization. Perioperative/intraoperative risk assessments such as preventive total gastrectomy or intraoperative assessment with indocyanine green fluorescence angiography may be desirable to avoid this complication.
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Affiliation(s)
- Jumpei Shibata
- Department of General Surgery, Toyohashi Municipal Hospital, 441-8570, 50 Aza Hachiken Nishi, Aotake-Cho, Toyohashi, Aichi, 441-8570, Japan.
| | - Motoi Yoshihara
- Department of General Surgery, Toyohashi Municipal Hospital, 441-8570, 50 Aza Hachiken Nishi, Aotake-Cho, Toyohashi, Aichi, 441-8570, Japan
| | - Takehito Kato
- Department of General Surgery, Toyohashi Municipal Hospital, 441-8570, 50 Aza Hachiken Nishi, Aotake-Cho, Toyohashi, Aichi, 441-8570, Japan
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5
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Denis Le Seve J, Gourraud Vercel C, Connault J, Artifoni M. [Update on cholesterol crystal embolism]. Rev Med Interne 2020; 41:250-257. [PMID: 32088097 DOI: 10.1016/j.revmed.2020.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 12/19/2019] [Accepted: 02/01/2020] [Indexed: 10/25/2022]
Abstract
Cholesterol crystal embolism is a systemic pathology associated with diffuse atherosclerosis. Pathophysiology corresponds to tissue necro-inflammation secondary to arteriolar occlusion associated with microembolism from atherosclerotic plaques of large diameter arteries. The clinical presentation is heterogeneous and polymorphic. Multiple organs may be the targets, but preferential damage is skin, kidneys and digestive system. It is a serious pathology, underdiagnosed, with a poor prognosis. The risk factors for developing the disease remain the same risk factors as atheroma. The factors favouring migration of microembolism remain mainly vascular interventional procedures; easy to diagnose, they oppose spontaneous embolic migrations or secondary to the introduction of antithrombotic treatment, whose diagnosis is more difficult and the prognosis more severe. The diagnosis of the disease remains mostly a diagnosis of elimination and often refers to a bundle of clinical, biological, morphological and histologic arguments. The treatment is poorly codified and the subject of few publications. It will favour both symptomatic treatment (and mainly that of pain) and complications (high blood pressure, renal insufficiency). The aetiological support remains less consensual. The treatment of atherosclerotic plaques consists, of course, in the correction of classical cardiovascular risk factors, the introduction of a statin. It will be discussed in the implementation of surgery or angioplasty to exclude potentially responsible atherosclerotic lesions. Eviction of antithrombotic therapy should be considered in terms of the benefit-risk balance, but often in favour of maintaining it. Finally, other treatments may be proposed in a case-by-case basis, such as oral or intravenous corticosteroid therapy, colchicine or LDL aphaeresis.
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Affiliation(s)
- J Denis Le Seve
- Service de médecine interne-vasculaire, centre hospitalier universitaire de Nantes, 1, place Alexis-Ricordeau, 44093 Nantes cedex 1, France.
| | - C Gourraud Vercel
- Service de néphrologie et immunologie clinique, centre hospitalier universitaire de Nantes, 30, boulevard Jean-Monnet, immeuble Jean-Monnet, 44093 Nantes cedex 1, France
| | - J Connault
- Service de médecine interne-vasculaire, centre hospitalier universitaire de Nantes, 1, place Alexis-Ricordeau, 44093 Nantes cedex 1, France
| | - M Artifoni
- Service de médecine interne-vasculaire, centre hospitalier universitaire de Nantes, 1, place Alexis-Ricordeau, 44093 Nantes cedex 1, France
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Hamroun A, Frimat M, Beuscart JB, Buob D, Lionet A, Lebas C, Daroux M, Provôt F, Hazzan M, Boulanger É, Glowacki F. [Kidney disease care for the elderly]. Nephrol Ther 2019; 15:533-552. [PMID: 31711751 DOI: 10.1016/j.nephro.2019.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
In our aging population, kidney disease management needs to take into account the frailty of the elderly. Standardized geriatric assessments can be proposed to help clinicians apprehend this dimension in their daily practice. These tools allow to better identify frail patients and offer them more personalized and harmless treatments. This article aims to focus on the kidney diseases commonly observed in elderly patients and analyze their specific nephrogeriatric care modalities. It should be noticed that all known kidney diseases can be also observed in the elderly, most often with a quite similar clinical presentation. This review is thus focused on the diseases most frequently and most specifically observed in elderly patients (except for monoclonal gammopathy associated nephropathies, out of the scope of this work), as well as the peculiarities of old age nephrological care.
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Affiliation(s)
- Aghilès Hamroun
- Service de néphrologie, hôpital Huriez, CHRU de Lille, 59037 Lille, France
| | - Marie Frimat
- Service de néphrologie, hôpital Huriez, CHRU de Lille, 59037 Lille, France
| | | | - David Buob
- Service d'anatomopathologie, Centre de biologie-pathologie, CHRU de Lille, 59037 Lille, France
| | - Arnaud Lionet
- Service de néphrologie, hôpital Huriez, CHRU de Lille, 59037 Lille, France
| | - Céline Lebas
- Service de néphrologie, hôpital Huriez, CHRU de Lille, 59037 Lille, France
| | - Maïté Daroux
- Service de néphrologie, hôpital Duchenne, allée Jacques Monod, 62200 Boulogne-sur-Mer, France
| | - François Provôt
- Service de néphrologie, hôpital Huriez, CHRU de Lille, 59037 Lille, France
| | - Marc Hazzan
- Service de néphrologie, hôpital Huriez, CHRU de Lille, 59037 Lille, France
| | - Éric Boulanger
- Service de gériatrie, CHRU de Lille, 59037 Lille, France
| | - François Glowacki
- Service de néphrologie, hôpital Huriez, CHRU de Lille, 59037 Lille, France.
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7
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Ozkok A. Cholesterol-embolization syndrome: current perspectives. Vasc Health Risk Manag 2019; 15:209-220. [PMID: 31371977 PMCID: PMC6626893 DOI: 10.2147/vhrm.s175150] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 05/10/2019] [Indexed: 12/16/2022] Open
Abstract
Cholesterol-embolization syndrome (CES) is a multisystemic disease with various clinical manifestations. CES is caused by embolization of cholesterol crystals (CCs) from atherosclerotic plaques located in the major arteries, and is induced mostly iatrogenically by interventional and surgical procedures; however, it may also occur spontaneously. Embolized CCs lead to both ischemic and inflammatory damage to the target organ. Therefore, anti-inflammatory agents, such as corticosteroids and cyclophosphamide, have been investigated as treatment for CES in several studies, with conflicting results. Recent research has revealed that CES is actually a kind of autoinflammatory disease in which inflammasome pathways, such as NLRP3 and IL1, are induced by CCs. These recent findings may have clinical implications such that colchicine and IL1 inhibitors, namely canakinumab, may be beneficial in the early stages of CES.
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Affiliation(s)
- Abdullah Ozkok
- Department of Internal Medicine and Nephrology, Memorial Şişli Hospital, Istanbul, Turkey
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8
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Rothenbühler M, Valgimigli M, Odutayo A, Frigoli E, Leonardi S, Vranckx P, Turturo M, Moretti L, Amico F, Uguccioni L, Contarini M, Gómez-Hospital JA, Mainar V, Creaco M, Petronio AS, Cremonesi A, Tamburino C, Fresco C, Bonmassari R, Díaz Fernández JF, Romagnoli E, Beyersmann J, Heg D, Jüni P. Association of acute kidney injury and bleeding events with mortality after radial or femoral access in patients with acute coronary syndrome undergoing invasive management: secondary analysis of a randomized clinical trial. Eur Heart J 2019; 40:1226-1232. [DOI: 10.1093/eurheartj/ehy860] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 06/29/2018] [Accepted: 11/30/2018] [Indexed: 01/01/2023] Open
Affiliation(s)
- Martina Rothenbühler
- CTU Bern, and Institute of Social and Preventive Medicine (ISPM), University of Bern, Mittelstrasse 43, Bern, Switzerland
| | - Marco Valgimigli
- Swiss Cardiovascular Center Bern, Bern University Hospital, Freiburgstrasse 8, Bern, Switzerland
| | - Ayodele Odutayo
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael’s Hospital, Department of Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, 30 Bond Street, Toronto, Ontario, Canada
| | - Enrico Frigoli
- CTU Bern, and Institute of Social and Preventive Medicine (ISPM), University of Bern, Mittelstrasse 43, Bern, Switzerland
| | - Sergio Leonardi
- Coronary Care Unit, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, Pavia, Italy
| | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Jessa Ziekenhuis, Stadsomvaart 11, 3500 Hasselt, Belgium, and Faculty of Medicine and Life Sciences, University of Hasselt, Martelarenlaan 42, Hasselt, Belgium
| | - Maurizio Turturo
- Division of Cardiology, P.O. Di Venere, Via Ospedale di Venere 1, Bari, Italy
| | - Luciano Moretti
- Division of Cardiology, Mazzoni Hospital, Via Degli Iris, Ascoli Piceno, Italy
| | - Francesco Amico
- Cardiology Unit, S. Elia Hospital, Via Luigi Russo 6, Caltanissetta, Italy
| | - Lucia Uguccioni
- Interventional Cardiology, Ospedali Riuniti Marche Nord, Piazzale Cinelli 4, Pesaro, Italy
| | - Marco Contarini
- Interventional Cardiology Unit, Umberto I Hospital, Via Testaferrata 1, Siracusa, Italy
| | - Joan Antoni Gómez-Hospital
- Heart Diseases Institute, Bellvitge University Hospital, Feixa Llarga s/n, L'Hospitalet, Barcelona, Spain
| | - Vicente Mainar
- Department of Cardiology, Hospital General of Alicante, Pintor Baeza 11, Alicante, Spain
| | - Manuela Creaco
- Cardiology Unit, Gravina Hospital, Via Portosalvo 9, Caltagirone, Italy
| | - Anna Sonia Petronio
- Unit of Interventional Cardiology, Cardiothoracic and Vascular Department, Ospedale di Cisanello, University of Pisa, Via Paradisa 2, Pisa, Italy
| | - Alberto Cremonesi
- Cardiovascular Department, Humanitas Gavazzeni Hospital, Via M. Gavazzeni 21, Bergamo, Italy
| | - Corrado Tamburino
- Cardiology Division, C.A.S.T. Policlinico University Hospital, Cardio-Thorax-Vascular and Transplant Department, Via S. Sofia 76, Catania, Italy
| | - Claudio Fresco
- Cardiology Unit, Azienda Sanitaria Universitaria Integrata di Udine, Piazzale S. Maria della Misericordia 15, Udine, Italy
| | - Roberto Bonmassari
- Division of Cardiology, Santa Chiara Hospital, Largo Medaglie D'oro 9, Trento, Italy
| | | | - Enrico Romagnoli
- Department of Cardiology, Fondazione Policlinico Universitario A. Gemelli, Largo Agostino Gemelli 8, Rome, Italy
| | - Jan Beyersmann
- Institute of Statistics, Ulm University, Helmholtzstrasse 20, Ulm, Germany
| | - Dik Heg
- CTU Bern, and Institute of Social and Preventive Medicine (ISPM), University of Bern, Mittelstrasse 43, Bern, Switzerland
| | - Peter Jüni
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael’s Hospital, Department of Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, 30 Bond Street, Toronto, Ontario, Canada
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9
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Gauckler P, Shin JI, Mayer G, Kronbichler A. Eosinophilia and Kidney Disease: More than Just an Incidental Finding? J Clin Med 2018; 7:E529. [PMID: 30544782 PMCID: PMC6306805 DOI: 10.3390/jcm7120529] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 11/29/2018] [Accepted: 12/05/2018] [Indexed: 02/07/2023] Open
Abstract
Peripheral blood eosinophilia (PBE), defined as 500 eosinophils or above per microliter (µL) blood, is a condition that is not uncommon but often neglected in the management of patients with chronic kidney disease (CKD), acute kidney injury (AKI), or patients on renal replacement therapy (RRT). The nature of PBE in the context of kidney diseases is predominantly secondary or reactive and has to be distinguished from primary eosinophilic disorders. Nonetheless, the finding of persistent PBE can be a useful clue for the differential diagnosis of underdiagnosed entities and overlapping syndromes, such as eosinophilic granulomatosis with polyangiitis (EGPA), IgG4-related disease (IgG4-RD), acute interstitial nephritis (AIN), or the hypereosinophilic syndrome (HES). For patients on RRT, PBE may be an indicator for bio-incompatibility of the dialysis material, acute allograft rejection, or Strongyloides hyperinfection. In a subset of patients with EGPA, eosinophils might even be the driving force in disease pathogenesis. This improved understanding is already being used to facilitate novel therapeutic options. Mepolizumab has been licensed for the management of EGPA and is applied with the aim to abrogate the underlying immunologic process by blocking interleukin-5. The current article provides an overview of different renal pathologies that are associated with PBE. Further scientific effort is required to understand the exact role and function of eosinophils in these disorders which may pave the way to improved interdisciplinary management of such patients.
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Affiliation(s)
- Philipp Gauckler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, 6020 Innsbruck, Austria.
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul 03722, Korea.
- Department of Pediatric Nephrology, Severance Children's Hospital, Seoul 03722, Korea.
- Institute of Kidney Disease Research, Yonsei University College of Medicine, Seoul 03722, Korea.
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA 30322, USA.
| | - Gert Mayer
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, 6020 Innsbruck, Austria.
| | - Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, 6020 Innsbruck, Austria.
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Murono K, Kawai K, Hata K, Emoto S, Kaneko M, Sasaki K, Nishikawa T, Otani K, Tanaka T, Ikemura M, Nozawa H. A case of anastomotic stenosis of the small intestine caused by cholesterol crystal embolism. Surg Case Rep 2018; 4:29. [PMID: 29619591 PMCID: PMC5884749 DOI: 10.1186/s40792-018-0442-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 03/28/2018] [Indexed: 03/04/2023] Open
Abstract
Background Cholesterol crystal embolism (CCE) is caused by small crystals of cholesterol dispersed from atherosclerotic plaques of the aorta. There is an increasing interest in CCE because of the increased use of endovascular treatments. Here, we report a rare case of intestinal stenosis caused by CCE after functional end-to-end anastomosis (FEEA). To our knowledge, this is the first report of CCE causing such an anastomotic stenosis. Case presentation A 77-year-old male patient underwent laparoscopy-assisted low anterior resection and protective ileostomy for rectal carcinoid tumor. He was admitted to our hospital with ileus 1 year after stoma closure. Eosinophils and creatine kinase level were slightly elevated. Computed tomography revealed a stricture with thickened intestinal wall just distal to the anastomosis site of the ileostomy. The wall of the descending aorta appeared shaggy due to thrombosis. The patient underwent laparoscopic small-bowel resection because ileus reoccurred after any oral intake. Histopathological findings of the resected specimen showed fibrotic changes distal to the anastomosis site, and needle-shaped cholesterol embolus was observed in the submucosal layer. Thus, the stenosis was considered to be caused by CCE. Conclusion This appears to be the first published report of stenosis due to CCE at such an anastomotic site. Intestinal CCE is difficult to diagnose preoperatively and is associated with poor prognosis. If eosinophilia is present or shaggy aorta is observed, CCE should be suspected to make correct diagnosis and prevent recurrence of CCE.
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Affiliation(s)
- Koji Murono
- Department of Surgical Oncology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Kazushige Kawai
- Department of Surgical Oncology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Keisuke Hata
- Department of Surgical Oncology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Shigenobu Emoto
- Department of Surgical Oncology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Manabu Kaneko
- Department of Surgical Oncology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Kazuhito Sasaki
- Department of Surgical Oncology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Takeshi Nishikawa
- Department of Surgical Oncology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Kensuke Otani
- Department of Surgical Oncology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Toshiaki Tanaka
- Department of Surgical Oncology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Masako Ikemura
- Department of Pathology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Hiroaki Nozawa
- Department of Surgical Oncology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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11
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Li X, Bayliss G, Zhuang S. Cholesterol Crystal Embolism and Chronic Kidney Disease. Int J Mol Sci 2017; 18:E1120. [PMID: 28538699 PMCID: PMC5485944 DOI: 10.3390/ijms18061120] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Revised: 05/19/2017] [Accepted: 05/20/2017] [Indexed: 01/01/2023] Open
Abstract
Renal disease caused by cholesterol crystal embolism (CCE) occurs when cholesterol crystals become lodged in small renal arteries after small pieces of atheromatous plaques break off from the aorta or renal arteries and shower the downstream vascular bed. CCE is a multisystemic disease but kidneys are particularly vulnerable to atheroembolic disease, which can cause an acute, subacute, or chronic decline in renal function. This life-threatening disease may be underdiagnosed and overlooked as a cause of chronic kidney disease (CKD) among patients with advanced atherosclerosis. CCE can result from vascular surgery, angiography, or administration of anticoagulants. Atheroembolic renal disease has various clinical features that resemble those found in other kidney disorders and systemic diseases. It is commonly misdiagnosed in clinic, but confirmed by characteristic renal biopsy findings. Therapeutic options are limited, and prognosis is considered to be poor. Expanding knowledge of atheroembolic renal disease due to CCE opens perspectives for recognition, diagnosis, and treatment of this cause of progressive renal insufficiency.
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Affiliation(s)
- Xuezhu Li
- Division of Nephrology, Tongji University School of Medicine, Shanghai 200120, China.
| | - George Bayliss
- Department of Medicine, Rhode Island Hospital and Alpert Medical School, Brown University, Providence, RI 02903, USA.
| | - Shougang Zhuang
- Division of Nephrology, Tongji University School of Medicine, Shanghai 200120, China.
- Department of Medicine, Rhode Island Hospital and Alpert Medical School, Brown University, Providence, RI 02903, USA.
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12
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Sanai T, Matsui R, Hirano T. LDL Apheresis for Cholesterol Embolism Following Coronary Artery Bypass Graft Surgery. Angiology 2016; 57:379-82. [PMID: 16703200 DOI: 10.1177/000331970605700316] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A 76-year-old man without any prior history of abnormal urinalysis findings or renal insufficiency demonstrated mild renal dysfunction after coronary bypass graft surgery (CABG). Two months after CABG, pain and blueness in the toes (blue toe syndrome) appeared and, the serum creatinine level (S-Cr) increased from 1.2 to 2.0 mg/dL. On admission (3 months later), the urinary protein level was 0.5 g/day, white blood cell count 8,300/μL with eosinophils (Eo) 10.5%, S-Cr 2.1 mg/dL, and low-density lipoprotein (LDL) 106 mg/dL. Acute renal failure and blue toe syndrome due to a cholesterol embolism (CE) were diagnosed. Alprostadil 40 μg/day orally for 2 weeks and alprostadil 40 μg/day intravenously were used for 5 weeks, and Eo were 250/μL, S-Cr 2.5 mg/dL; however, blue toe syndrome gradually developed. At 8 weeks after admission, limaprost alfadex 30 μg/day orally was used for 3 weeks. However, the Eo gradually rose to 1,520/μL, S-Cr to 3.0 mg/dL, and LDL to 135 mg/dL, and LDL apheresis was therefore performed 20 times for CE. The data just after LDL apheresis was performed 10 times were as follows: Eo 1,120/μL, S-Cr 4.0 mg/dL, and LDL 89 mg/dL, and blue toe syndrome had disappeared. At 10 months after the first LDL apheresis, the Eo were 630/μL, S-Cr 2.9 mg/dL, and LDL 109 mg/dL. As a result, LDL apheresis was found to be beneficial for the treatment of CE with acute renal failure and blue toe syndrome after CABG.
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Affiliation(s)
- Toru Sanai
- Division of Nephrology, Department of Internal Medicine and Clinical Research Institute, National Kyushu Medical Center, Fukuoka, Japan.
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13
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Abstract
Atheromatous embolization is a multisystem disease complicating advanced atherosclerosis. It occurs most often as a complication of angiography, an endovascular procedure or cardiovascular surgery. Atheromatous embolization can present in a subtle manner where it is often under-recognized, or with catastrophic results including myocardial infarction, strake or acute renal failure. It may mimic other disease processes and often goes underdiagnosed and undertreated. A high clinical suspicion is the key to diagnosis. Atheromatous embolization results in significant morbidity and mortality; therefore, early recognition followed by aggressive management may help to prevent end-organ damage and improve overall clinical outcomes. Management strategies should include risk factor modification, prevention of further insults by discontinuing or avoiding predisposing factors, supportive treatment and interventional or surgical approaches to remove the atheroembolic source. Atheromatous embolization is expected to increase as our population ages and the epidemics of diabetes mellitus and obesity increase.
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Affiliation(s)
- Yin Ping Liew
- Department of Cardiovascular Medicine, Section of Vascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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Abstract
Distal peripheral microembolism is caused by embolization of atherosclerotic debris into small arteries and arterioles. The recent advances in endovascular technique have been met with a gradual increase in the incidence of iatrogenic atheroembolism. This review seeks to explore the nature of distal peripheral microembolism, pathophysiology, and the management options, with a focus on iatrogenic distal peripheral microembolism.
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Affiliation(s)
- Joe R Chauvapun
- Department of Surgery, State University of New York, Buffalo, NY, USA.
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Kim SH, Kang KM, Yu A, Lee JH, Nam BH, Lee ES. A Study of Relationship of Atheroembolic Risk Factors with Postoperative Recovery in Renal Function after Partial Nephrectomy in Patients Staged T1-2 Renal Cell Carcinoma during Median 4-Year Follow-up. Cancer Res Treat 2015; 48:288-96. [PMID: 25943322 PMCID: PMC4720065 DOI: 10.4143/crt.2014.297] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Accepted: 03/16/2015] [Indexed: 01/20/2023] Open
Abstract
Purpose The objective of this study is to evaluate the relationship of atheroembolic risk factors with postoperative recovery of renal function after on-clamp partial nephrectomy (PN) with warm ischemia in patients with staged T1-2 renal cell carcinoma (RCC). Materials and Methods A total of 234 patients from 2004 to 2012 were included, and their clinicopathologic and operative parameters, including atheroembolic risk factors were reviewed retrospectively. Renal function, as determined by estimated glomerular filtration rate (eGFR) and measurement of serum creatinine level (Cr) at each scheduled follow-up for a median four years, was compared between the high-risk (HR) group (n=49, ≥ five risk factors) and the low-risk (LR) group (n=185, < five risk factors). Results Except for baseline renal function and number of risk factors for atheroembolism, differences in characteristics between groups were comparatively insignificant. At 3 months after the operation, Cr and eGFR differed significantly between the two groups (p < 0.05), but no differences were observed afterward. Significant deterioration from baseline in Cr and eGFR was observed in both groups at 1 month after the operation, with a greater change in the HR group (p < 0.05). From measurement to measurement, significantly faster deterioration in Cr and eGFR was observed in the HR group than in the LR group until 6 months after the operation (Cr: LR, 0.02 mg/dL and HR, 0.13 mg/dL; eGFR: LR, 1.50 mL/min/1.73 m2 and HR, 6.38 mL/min/1.73 m2; p < 0.05). Conclusion The presence of atheroembolic risk factors may negatively influence postoperative recovery of renal function after PN in patients with localized RCC.
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Affiliation(s)
- Sung Han Kim
- Department of Urology, National Cancer Center, Goyang, Korea
| | - Kyung Min Kang
- Biometric Research Branch, National Cancer Center, Goyang, Korea
| | - Ami Yu
- Biometric Research Branch, National Cancer Center, Goyang, Korea
| | - Jung Hoon Lee
- Department of Urology, Seoul National University Hospital, Seoul, Korea
| | - Byung Ho Nam
- Department of Cancer Control and Policy, Graduate School of Cancer Science and Policy, National Cancer Center, Goyang, Korea
| | - Eun Sik Lee
- Department of Urology, Seoul National University Hospital, Seoul, Korea
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Borges MV, Gomes A, Pinheiro PSDA, Conceição AND, Ataíde SCD. Utilização de prostaglandina sintética no tratamento da embolia sistêmica de cristais de colesterol, após tratamento endovascular de aneurisma da aorta abdominal. J Vasc Bras 2012. [DOI: 10.1590/s1677-54492012000100014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
| | - Adriano Gomes
- Instituto de Radiologia Intervencionista e Cirurgia Endovascular, Brasil
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Peripheral vascular complication from coronary angiography: A case report of cholesterol embolization. Int J Angiol 2011. [DOI: 10.1007/s00547-006-1098-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Abstract
Atheroembolic renal disease develops when atheromatous aortic plaques rupture, releasing cholesterol crystals into the small renal arteries. Embolisation often affects other organs, such as the skin, gastrointestinal system, and brain. Although the disease can develop spontaneously, it usually develops after vascular surgery, catheterisation, or anticoagulation. The systemic nature of atheroembolism makes diagnosis difficult. The classic triad of a precipitating event, acute or subacute renal failure, and skin lesions, are strongly suggestive of the disorder. Eosinophilia further supports the diagnosis, usually confirmed by biopsy of an affected organ or by the fundoscopic finding of cholesterol crystals in the retinal circulation. Renal and patient prognosis are poor. Treatment is mostly preventive, based on avoidance of further precipitating factors, and symptomatic, aimed to the optimum treatment of hypertension and cardiac and renal failure. Statins, which stabilise atherosclerotic plaques, should be offered to all patients. Steroids might have a role in acute or subacute progressive forms with systemic inflammation.
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Fries C, Roos M, Gaspert A, Vogt P, Salomon F, Wüthrich RP, Vavricka SR, Fehr T. Atheroembolic disease--a frequently missed diagnosis: results of a 12-year matched-pair autopsy study. Medicine (Baltimore) 2010; 89:126-132. [PMID: 20517183 DOI: 10.1097/md.0b013e3181d5eb39] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Diagnosis of atheroembolic disease (AD) is challenging, because no specific test is available and AD often masquerades as other clinical conditions. We conducted the current study to investigate the relative frequency of autopsy-proven AD over time, to describe its clinical presentation, and to identify risk factors for AD. We screened 2066 autopsy reports from 1995 to 2006 for AD. For each AD case, a control patient without AD was matched for age, sex, and autopsy year. Diagnostic and therapeutic interventions (surgery, catheter interventions, and drug treatment) in the last 6 months before death, as well as clinical and laboratory parameters during the last hospitalization, were retrieved from electronic charts. We identified 51 patients with AD. Among these only 6 (12%) had been diagnosed clinically. The organs most often affected were kidney (71%), spleen (37%), and lower gastrointestinal tract (22%). The relative AD frequency decreased over time from 3.5 to 0.5 per 100 autopsies, whereas the frequency of clinically suspected and biopsy-proven AD remained constant. Among clinical signs, skin lesions such as livedo reticularis and blue toe (33% vs. 14%; p = 0.04) were significantly increased in AD patients compared with the matched controls. We also observed a trend for higher incidence of eosinophilia and proteinuria in AD patients. Vascular interventions within 6 months before death were highly associated with AD (55% vs. 29%; p = 0.01), and in a multivariable analysis this remained the only significant risk factor for AD. Thus, the diagnosis of AD is frequently missed. Vascular interventions represent the most important risk factor for AD and should be performed restrictively in high-risk patients.
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Affiliation(s)
- Caroline Fries
- From Division of Nephrology (CF, RPW, TF), Department of Pathology (AG, PV), Division of Gastroenterology and Hepatology (SRV), University Hospital Zürich, Zürich; Biostatistics Unit (MR), Institute of Social and Preventive Medicine, University of Zürich, Zürich; and Clinic for Internal Medicine (FS), Regional Hospital Lachen, Lachen, Switzerland
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Hirschmann JV, Raugi GJ. Blue (or purple) toe syndrome. J Am Acad Dermatol 2009; 60:1-20; quiz 21-2. [DOI: 10.1016/j.jaad.2008.09.038] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2008] [Revised: 08/26/2008] [Accepted: 09/03/2008] [Indexed: 01/19/2023]
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Paraskevas KI, Koutsias S, Mikhailidis DP, Giannoukas AD. Cholesterol Crystal Embolization:A Possible Complication of Peripheral Endovascular Interventions. J Endovasc Ther 2008; 15:614-25. [DOI: 10.1583/08-2395.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Caciolli S, Rostagno C, Fradella G, Margheri M, Stefano P. Coronary embolism following valve surgery. J Cardiovasc Med (Hagerstown) 2008; 9:406-7. [PMID: 18334897 DOI: 10.2459/jcm.0b013e3282eee877] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 55-year-old man experienced chest pain on the seventh day after valve surgery. Coronary angiography showed embolic occlusion of the left anterior descending coronary artery. The lesion was treated successfully with thrombectomy using the angiojet rheolytic thrombectomy system, resulting in rapid mechanical thrombolysis and removal via the effluent lumen of the catheter. Thrombolysis in Myocardial Infarction 3 flow was restored.
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Affiliation(s)
- Sabina Caciolli
- Division of Cardiology, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
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Abstract
BACKGROUND Warfarin therapy has been used clinically for over 60 years, yet continues to be problematic because of its narrow therapeutic index and large inter-individual variability in patient response. As a result, warfarin is a leading cause of serious medication-related adverse events, and its efficacy is also suboptimal. OBJECTIVE To review factors that are responsible for variable response to warfarin, including clinical, environmental, and genetic factors, and to explore some possible approaches to improving warfarin therapy. RESULTS Recent efforts have focused on developing dosing algorithms that included genetic information to try to improve warfarin dosing. These dosing algorithms hold promise, but have not been fully validated or tested in rigorous clinical trials. Perhaps equally importantly, adherence to warfarin is a major problem that should be addressed with innovative and cost-effective interventions. CONCLUSION Additional research is needed to further test whether interventions can be used to improve warfarin dosing and outcomes.
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Affiliation(s)
- Stephen E Kimmel
- University of Pennsylvania School of Medicine, Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, 717 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104-6021, USA.
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Mittal BV, Alexander MP, Rennke HG, Singh AK. Atheroembolic renal disease: a silent masquerader. Kidney Int 2007; 73:126-30. [PMID: 17667989 DOI: 10.1038/sj.ki.5002433] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- B V Mittal
- Renal Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
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Scolari F, Ravani P, Gaggi R, Santostefano M, Rollino C, Stabellini N, Colla L, Viola BF, Maiorca P, Venturelli C, Bonardelli S, Faggiano P, Barrett BJ. The challenge of diagnosing atheroembolic renal disease: clinical features and prognostic factors. Circulation 2007; 116:298-304. [PMID: 17606842 DOI: 10.1161/circulationaha.106.680991] [Citation(s) in RCA: 116] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Atheroembolic renal disease (AERD) is caused by showers of cholesterol crystals released by eroded atherosclerotic plaques. Embolization may occur spontaneously or after angiographic/surgical procedures. We sought to determine clinical features and prognostic factors of AERD. METHODS AND RESULTS Incident cases of AERD were enrolled at multiple sites and followed up from diagnosis until dialysis and death. Diagnosis was based on clinical suspicion, confirmed by histology or ophthalmoscopy for all spontaneous forms and for most iatrogenic cases. Cox regression was used to model time to dialysis and death as a function of baseline characteristics, AERD presentation (acute/subacute versus chronic renal function decline), and extrarenal manifestations. Three hundred fifty-four subjects were followed up for an average of 2 years. They tended to be male (83%) and elderly (60% >70 years) and to have cardiovascular diseases (90%) and abnormal renal function at baseline (83%). AERD occurred spontaneously in 23.5% of the cases. During the study, 116 patients required dialysis, and 102 died. Baseline comorbidities, ie, reduced renal function, presence of diabetes, history of heart failure, acute/subacute presentation, and gastrointestinal tract involvement, were significant predictors of event occurrence. The risk of dialysis and death was 50% lower among those receiving statins. CONCLUSIONS Clinical features of AERD are identifiable. These make diagnosis possible in most cases. Prognosis is influenced by disease type and severity.
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Affiliation(s)
- Francesco Scolari
- Division of Nephrology, University and Spedali Civili, Brescia, Italy.
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Piccoli GB, Fenoglio R, Colla L, Bilucaglia D, Mezza E, Burdese M, Bermond F, Segoloni GP. Cholesterol Crystal Embolism Syndrome in Dialysis Patients: An Emerging Clinical Diagnosis? Blood Purif 2006; 24:433-8. [PMID: 16940713 DOI: 10.1159/000095359] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2005] [Accepted: 01/05/2006] [Indexed: 11/19/2022]
Abstract
BACKGROUND Cholesterol crystal embolism syndrome (CCE) is an increasing end-stage renal disease cause. Few cases have been described on dialysis, despite the high prevalence of the predisposing factors. METHODS The diagnostic criteria of the present study were: skin lesions, myalgia, fatigue, fever and acute inflammatory serologic signs, in the presence of severe vasculopathy. The precipitating factors were: anticoagulation, endovascular intervention and ulcerated atherosclerotic plaque. RESULTS Between October 2003 and September 2005, CCE was diagnosed in 6 dialysis patients (of 200-210 on chronic treatment): 5 males, 1 female, median age 59.5 years (47-70) and end-stage renal disease follow-up 11.5 years (3-25). All had severe vasculopathy, 5 cardiopathy, and 4 were failed graft recipients. The treatment included: peritoneal dialysis, daily dialysis, 'conventional' hemodialysis (2 cases) and hemodiafiltration. The diagnosis was based on the clinical-laboratory picture in 1 patient. In the 5 others clues were present (dicumarol therapy, angioplasty, femoral artery thrombosis, CCE predialysis and ulcerated aortic plaque). The therapeutic approach consisted of corticosteroids (5 cases), statins (4 cases) and prostaglandin analogues (4 cases). CONCLUSION The differential diagnosis of CCE should also be considered in dialysis patients (necrotic lesions, limb pain and vasculitis-like signs).
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Venturelli C, Jeannin G, Sottini L, Dallera N, Scolari F. Cholesterol crystal embolism (atheroembolism). Heart Int 2006; 2:155. [PMID: 21977265 PMCID: PMC3184670 DOI: 10.4081/hi.2006.155] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Cholesterol crystal embolism, known as atheroembolic disease, is caused by showers of cholesterol crystals from an atherosclerotic plaque that occludes small arteries. Embolization can occur spontaneously or as an iatrogenic complication from an invasive vascular procedure (angiography or vascular surgery) and after anticoagulant therapy. The atheroembolism can give rise to different degrees of renal impairment. Some patients show a moderate loss of renal function, others severe renal failure requiring dialysis. Renal outcome can be variable: some patients deteriorate or remain on dialysis, some improve and some remain with chronic renal impairment. Clinically, three types of atheroembolic renal disease have been described: acute, subacute or chronic. More frequently a progressive loss of renal function occurs over weeks. Atheroembolization can involve the skin, gastrointestinal system and central nervous system. The diagnosis is difficult and controversial for the protean extrarenal manifestations. In the past, the diagnosis was often made post-mortem. In the last 10 yrs, awareness of atheroembolic renal disease has improved. The correct diagnosis requires the clinician to be alert. The typical patient is a white male aged >60 yrs with a history of hypertension, smoking and arterial disease. The presence of a classic triad (precipitating event, renal failure and peripheral cholesterol crystal embolization) suggests the diagnosis. This can be confirmed by a biopsy of the target organs. A specific treatment is lacking; however, it is an important diagnosis to make because an aggressive therapeutic approach can be associated with a more favorable clinical outcome.
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Affiliation(s)
- Chiara Venturelli
- Scuola di Specializzazione in Nefrologia Clinica, Università degli Studi di Brescia, Brescia - Italy
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Jucgla A, Moreso F, Muniesa C, Moreno A, Vidaller A. Cholesterol embolism: Still an unrecognized entity with a high mortality rate. J Am Acad Dermatol 2006; 55:786-93. [PMID: 17052483 DOI: 10.1016/j.jaad.2006.05.012] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2006] [Revised: 04/28/2006] [Accepted: 05/05/2006] [Indexed: 12/27/2022]
Abstract
BACKGROUND Cholesterol embolism (CE) is an increasingly common but often underdiagnosed medical problem. The recognition of clinical manifestations of CE is the first step toward a correct diagnosis. OBJECTIVE Our aim was to characterize the features of CE and the risk factors for fatal outcome. METHODS Clinical records of patients with clinical and histopathologic diagnoses of CE seen from January 1993 through March 2003 were reviewed. RESULTS Twenty-six male patients were identified. Mean age was 64 years (range, 48-88 years). All patients had two or more risk factors for atherosclerosis. All but one patient had preexisting symptomatic atherosclerotic disease. At least one precipitating factor was identified in 23 patients (88%). Diagnosis of CE at admission was made in 9 patients only (35%). Cutaneous lesions (88%) and renal failure (73%) were the most common clinical findings. Complications (dialysis, acute pulmonary edema, amputation, or gastrointestinal surgery) were present in 21 patients (81%), and 15 patients died (58%). Previous chronic renal failure was the only variable associated with mortality (relative risk: 4.54, 95% confidence interval 1.26-16.6; P = .02). LIMITATIONS The results were obtained from patients admitted to a university hospital. This fact may have selected a higher proportion of severe cases. CONCLUSIONS CE was frequently misdiagnosed. Skin lesions were the most common clinical findings and skin biopsy provided histologic confirmation in most of the patients. Chronic renal failure was the only factor related to death.
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Affiliation(s)
- Anna Jucgla
- Department of Dermatology, Hospital Universitari de Bellvitge, University of Barcelona, Spain.
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Kono Y, Takizawa H, Yamaji I, Takada T, Shinohara T, Tanaka S, McGill RL. Pulmonary atheroembolism via an AV shunt. J Vasc Access 2006; 7:139-42. [PMID: 17019668 DOI: 10.1177/112972980600700310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Although cholesterol crystal embolism can present with diffuse visceral involvement, lung lesions do not occur unless there is left to right circulatory shunting. Pulmonary atheroembolism was confirmed by histology in an elderly male with recent end-stage renal failure (ESRF) due to atheroembolic renal disease, who presented with massive hemoptysis and intractable respiratory failure. At autopsy, atheromatous degeneration of the aorta was observed and acute cholesterol emboli found in the kidneys, spleen, liver, stomach and lung. Cholesterol clefts were seen in pulmonary arterioles, and ischemic alveolar damage was present. The pulmonary arteries had no atheromatous changes. Intrapulmonary, intracardiac, and aortocaval shunting were not present. Pulmonary atheroembolism arising from a dialysis fistula has not been previously reported.
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Affiliation(s)
- Y Kono
- Department of Nephrology, Teine Keijinkai Hospital, Teine-Ku, Sapporo, Japan.
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Cheng C, Tsuneyama K, Zheng H, Oya T, Cui Z, Feril LB, Takano Y. Enhanced scavenging of lipid substances is a possible effect of corticosteroids in the treatment of cholesterol crystal embolism. Pathol Res Pract 2006; 202:591-8. [PMID: 16814943 DOI: 10.1016/j.prp.2006.04.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2006] [Accepted: 04/04/2006] [Indexed: 10/24/2022]
Abstract
Cholesterol crystal embolism (CCE) is a systemic refractory disease especially prevalent amongst elderly patients suffering from atherosclerosis. Treatment of this condition remains controversial due to difficulties in diagnosis. Corticosteroid therapy may be an important treatment option despite its elusive mechanisms. To clarify the role of corticosteroid in CCE therapy, we collected the samples from six autopsied subjects with CCE, three of whom were clinically given various doses of corticosteroid to investigate stable atherosclerosis-related substances, advanced glycation end-products (AGE), and several AGE receptors such as scavenger receptor class B type 1 (SR-B1), receptor for AGE (RAGE), and galectin-3 in the liver tissues and atherosclerotic areas by immunostaining using a tissue macro-array technique. An intense expression of AGE and its receptors was identified in the enlarged Kupffer cells of CCE cases, which were given relatively high doses of corticosteroid. In addition, numerous mononuclear cells in the intimal atheromatous plaque presented strong expressions of AGE and SR-B1. In conclusion, we speculated that corticosteroid treatment for CCE may upregulate the activations, including phagocytic capacity of Kupffer cells mediated by overexpression of RAGE and scavenger receptors, resulting in efficient clearance of the lipid substances from the blood circulation released from atherosclerotic areas.
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Affiliation(s)
- Chunmei Cheng
- Department of Pathology (I), School of Medicine, University of Toyama, 2630 Sugitani, Toyama 930-0194, Japan
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Piccoli GB, Maddalena E, Fenoglio R, Bilucaglia D, Mezza E, Colla L, Rabbia C, Segoloni GP. The long-term dialysis patient with purple-blue toes. Nephrol Dial Transplant 2006; 21:2022-3. [PMID: 16627616 DOI: 10.1093/ndt/gfl136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Affiliation(s)
- Krishna R Polu
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Massachusetts General Hospital, Boston, MA 02114, USA
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Venturelli C, Jeannin G, Sottini L, Dallera N, Scolari F. Cholesterol Crystal Embolism (Atheroembolism). Heart Int 2006. [DOI: 10.1177/1826186806002003-404] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Chiara Venturelli
- Scuola di Specializzazione in Nefrologia Clinica, Università degli Studi di Brescia, Brescia - Italy
| | - Guido Jeannin
- Scuola di Specializzazione in Nefrologia Clinica, Università degli Studi di Brescia, Brescia - Italy
| | - Laura Sottini
- Scuola di Specializzazione in Nefrologia Clinica, Università degli Studi di Brescia, Brescia - Italy
| | - Nadia Dallera
- Scuola di Specializzazione in Nefrologia Clinica, Università degli Studi di Brescia, Brescia - Italy
| | - Francesco Scolari
- Scuola di Specializzazione in Nefrologia Clinica, Università degli Studi di Brescia, Brescia - Italy
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Piccoli GB, Sargiotto A, Burdese M, Colla L, Bilucaglia D, Magnano A, Consiglio V, Piccoli G, Picciotto G. Cholesterol emboli syndrome in type 2 diabetes: the disease history of a case evaluated with renal scintigraphy. Rev Diabet Stud 2005; 2:92-6. [PMID: 17491684 PMCID: PMC1783551 DOI: 10.1900/rds.2005.2.92] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Cholesterol crystal emboli syndrome (CCE) is an emerging disease, whose progression reflects the currently observed increase in cardiovascular diseases. Diagnostic criteria shifted from pathological to clinical criteria: creatinine increase, skin lesions, recent endovascular interventions and severe vasculopathy). Diabetes, hypertension and diffuse vascular disease are inter-linked, major risk factors. The role of imaging techniques in the diagnosis and treatment of the disease has been little investigated thus far. The AIM of this report is to describe a case exemplifying the potentials for renal scintigraphy in CCE, an emerging disease in type 2 diabetic patients. THE CASE A 75 year-old, type 2 diabetic for over 15 years, obese, hypertensive white man was referred to the Nephrology Unit after an acute coronary syndrome. Stenosis of the left renal artery was diagnosed from the angiography. Serum creatinine (baseline: 1.9 mg/dl) increased after multiple angioplasties to 3.3 mg/dl, then slowly returned towards baseline (2.2 mg/dl), but rose, on referral, to 3.9 mg/dl, with an increase in acute phase reactants and peripheral livedo reticularis, a picture highly suggestive of CCE. The first renal scintiscan showed a reduction of the parenchymal phase, and a non-homogeneous parenchymal pattern in the right dominant kidney. The patient was started on corticosteroid therapy with a prompt decrease in creatinine; four days later (creatinine 2.5 mg/dl) a second scintiscan showed an improvement of the peak time and of the radionuclide parenchymal transit, and was further confirmed two months later (creatinine 2.2 mg/dl). No modification was detected in the left kidney, presumably mechanically "protected" from the cholesterol shedding by the stenosis. CONCLUSIONS This is the first description of an imaging demonstration of the morpho-functional substratum to the rapid clinical response of corticosteroid therapy in a case of CCE and type 2 diabetes, underlining the potential of 99mTc-MAG3 dynamic scintiscan in this disease.
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Affiliation(s)
- Giorgina B Piccoli
- Department of Internal Medicine, University of Turin, Corso Bramante 86-88, 10126 Torino, Italy.
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Ricciardi D, Rossi D, Fagugli RM. Massive bowel infarction after percutaneous transluminal renal angioplasty. Nephrol Dial Transplant 2005; 20:2259-61. [PMID: 16030049 DOI: 10.1093/ndt/gfh975] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Daniela Ricciardi
- S.C. Nefrologia e Dialisi, Ospedale Silvestrini, Azienda Ospedaliera di Perugia, San Andrea delle Fratte, 06100 Perugia, Italy
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Tsao CR, Lee WL, Liu TJ, Chen YT, Ting CT. Delicate Percutaneous Renal Artery Stenting Minimizes Postoperative Renal Injury and Protects Kidney in Patients With Severe Atherosclerotic Renal Artery Stenosis and Impaired Renal Function. Int Heart J 2005; 46:1061-72. [PMID: 16394602 DOI: 10.1536/ihj.46.1061] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Percutaneous transluminal renal artery stenting (PTRAS) is associated with declining renal function in a non-negligible portion of patients and is inflicted by different mechanisms, including atheroembolism. This study investigated whether delicate PTRAS to reduce atheroembolism might minimize postoperative renal injury and better preserve renal function. Patients undergoing PTRAS performed by experienced interventional cardiologists, applying coronary intervention concepts, techniques, devices and delicacy principles whenever possible, were prospectively studied. A total of 34 patients (29 M/5 F) with impaired renal function (group A, creatinine 2.4 +/- 0.1 mg/dL) and another 20 patients (16 M/4 F) with normal serum creatinine (group B, baseline creatinine 1.2 +/- 0.0 mg/dL) were studied. PTRAS was successfully performed in all but one group A patient. During a 6-month follow-up, systolic and diastolic blood pressure (130 +/- 2 versus 148 +/- 4 mmHg, P = 0.001 and 70 +/- 2 versus 78 +/- 3 mmHg, P = 0.006) and serum creatinine (2.1 +/- 0.1 versus 2.4 +/- 0.1 mg/dL, P < 0.001) were all significantly lowered in group A patients. Using a 20% change cut-off value, renal function improved in eight (24%), remained unchanged in 24 patients (73%), and deteriorated in only one patient (3%). The corresponding alterations in blood pressure and renal function were insignificant in group B patients. Patients with bilateral involvement (eleven patients) also had significantly lowered serum creatinine on follow-up. In conclusion, delicately practiced PTRAS can reduce the rate of postprocedural renal deterioration in patients with impaired renal function, and should be adopted in every renal intervention.
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Affiliation(s)
- Chen-Rong Tsao
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
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Henry M, Henry I, Klonaris C, Polydorou A, Rath P, Lakshmi G, Rajacopal S, Hugel M. Renal angioplasty and stenting under protection: The way for the future? Catheter Cardiovasc Interv 2003; 60:299-312. [PMID: 14571477 DOI: 10.1002/ccd.10669] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The purpose of this study was to evaluate the feasibility and safety of renal artery angioplasty and stenting utilizing a distal protection device to reduce the risk of intraprocedural artery embolism and avoid deterioration of the renal function. Fifty-six hypertensive patients (32 men; mean age, 66 +/- 11.8 years; range, 22-87) with atherosclerotic renal artery stenosis (8 bilateral) underwent angioplasty and stenting with distal protection in 65 renal arteries (58 ostial lesions). Five patients had a solitary kidney, 18 a renal insufficiency. The lesion was crossed either with a GuardWire temporary occlusion balloon (n = 38), which was inflated to provide parenchyma protection or with a filter (EPI Filter; n = 26), or with Angioguard (n = 1), which allows a continuous flow. Generated debris was aspirated and analyzed. Blood pressure and serum creatinine levels were followed. Immediate technical success was 100%. All lesions except one were stented, either directly (43 ostial lesions) or after predilatation (22 ostial lesions). Visible debris were aspirated with the PercuSurge in all patients or removed with filters in 80% of the patients. Mean particle number and diameter were 98.1 +/- 60.0 per procedure (range, 13-208) and 201.0 +/- 76.0 microm (range, 38-6,206), respectively. Mean renal artery occlusion time was 6.55 +/- 2.46 min (range, 2.29-13.21) with the PercuSurge device. Mean time in situ (filters) was 4.25 +/- 1.12 min. Mean follow-up was 22.6 +/- 17.6 months (range, 1-47). Systolic and diastolic blood pressure declined from 169.0 +/- 15.2 and 104.0 +/- 13.0 mm Hg, respectively, to 149.7 +/- 12.4 and 92.7 +/- 6.7 mm Hg after the procedure. The mean creatinine level remains constant during the follow-up. At 6-month follow-up (45 patients), renal function did not deteriorate in any patient, whereas 8 patients with baseline renal insufficiency improved after the procedure. At 3 years (19 patients), renal function deteriorated only in 1 patient with renal insufficiency and in 1 patient treated for bilateral renal stenosis, one side without protection. These preliminary results suggest the feasibility and safety of distal protection during renal interventions to protect against atheroembolism and to avoid renal function deterioration. This technique's beneficial effects should be evaluated by randomized studies.
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Donohue KG, Saap L, Falanga V. Cholesterol crystal embolization: an atherosclerotic disease with frequent and varied cutaneous manifestations. J Eur Acad Dermatol Venereol 2003; 17:504-11. [PMID: 12941082 DOI: 10.1046/j.1468-3083.2003.00710.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
In this paper the basic pathogenesis of cholesterol crystal embolization (CCE) is described, its clinical characteristics are presented and diagnosis and therapy are discussed. The main focus will be on the cutaneous manifestations; however, considering that CCE is a systemic illness, findings in other organs will also be highlighted, particularly the commonly involved renal and gastrointestinal systems.
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Affiliation(s)
- K G Donohue
- Department of Dermatology and Skin Surgery, Roger Williams Medical Center, Providence, Rhode Island, USA
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Ben-Horin S, Bardan E, Barshack I, Zaks N, Livneh A. Cholesterol crystal embolization to the digestive system: characterization of a common, yet overlooked presentation of atheroembolism. Am J Gastroenterol 2003; 98:1471-9. [PMID: 12873565 DOI: 10.1111/j.1572-0241.2003.07532.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In the 1359 published patients with multiorgan cholesterol crystal embolism (CCE), the digestive system seems to be the third most frequently affected system. Yet, this system received hitherto only little attention in the medical literature. Therefore, the aim of the present study was to clinically characterize the subset of patients with CCE involving the digestive system, based on our institutional experience and a review of the literature. Cases with CCE in a 7-yr period (1995-2001) were sought in the computerized records of our medical center. Of the CCE patients, those with digestive system involvement that could be related to CCE were included in this study. The clinical features of CCE were determined and compared with those found in published series. Fourteen cases with CCE were identified, giving an annual incidence of 0.8 per 10(5). Digestive system involvement was found in five (36%) of the 14 patients. All five patients had established atherosclerosis. Precipitating factors were vascular manipulations or anticoagulation treatment in four of these five patients. Two patterns of disease appeared: acute catastrophic multiorgan disorder with poor prognosis and chronic and more indolent GI disease. Abdominal pain, GI bleeding, fever, and diarrhea were the most common manifestations, resulting from bowel infarction, mucosal ulcerations, hepatocellular liver disorder, and/or pancreatitis. CCE is a systemic disorder with a frequent involvement of the digestive system and protean clinical manifestations. It should, therefore, be considered in any gastroenterological patient with atherosclerosis and recent vascular manipulations or systemic anticoagulation.
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Affiliation(s)
- Shomron Ben-Horin
- Department of Medicine F, Sheba Medical Center, Tel Hashomer, and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Abstract
The many manifestations of atheroembolism are apparent in all specialties. However, with increasing intervention in older patients with atherosclerotic disease, it has become an important renal clinical problem. Atheroembolic disease is widely recognized as a cause of acute catastrophic renal dysfunction and recent important data have suggested that effective management protocols can improve outcome. It is probable that the clinical course is insidious in the majority of patients with severe atherosclerotic aortic disease. The management of these patients is less clear and at present rests on small anecdotal reports.
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Affiliation(s)
- John S. Smyth
- Department of Renal Medicine, Guy's and St. Thomas Trust, St. Thomas Street, London SE1 9RT, United Kingdom.
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Pennington M, Yeager J, Skelton H, Smith KJ. Cholesterol embolization syndrome: cutaneous histopathological features and the variable onset of symptoms in patients with different risk factors. Br J Dermatol 2002; 146:511-7. [PMID: 11952556 DOI: 10.1046/j.1365-2133.2002.04611.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Cholesterol embolization syndrome (CES) may not only be due to direct dislodgement of cholesterol crystals from atherosclerotic plaques on the walls of arteries by surgery, angiogram or trauma, but may occur after anticoagulant and thrombolytic therapy. The latter two therapies both weaken the fibrin clot that stabilizes the atheromas in place; however, these two therapies commonly have different onsets of CES after their institution. We present three patients with different risk factors for CES who all presented with the pathognomonic triad of leg and/or foot pain, livedo reticularis and good peripheral pulses. In all three patients cholesterol emboli were demonstrated in cutaneous biopsy sections. In two patients there was associated renal involvement, which was fatal in one case. These cases illustrate that cutaneous biopsy may be diagnostic in patients with livedo reticularis, which progresses to necrosis and gangrene. In addition, they illustrate the problems and contradictions involved in treating patients with CES.
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Affiliation(s)
- M Pennington
- Department of Dermatology and Pathology, National Naval Medical Center, Bethesda, MD, USA
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Gómez de la Fuente E, Javier Vicente Martín F, Gregorio Álvarez Fernández J, Sols Candela M, Rodríguez Vázquez M, Luis López Estebaranz J, Pinedo Moraleda F. Embolismo por cristales de colesterol, con fracaso renal agudo o subagudo, diagnosticado por las lesiones cutáneas. ACTAS DERMO-SIFILIOGRAFICAS 2002. [DOI: 10.1016/s0001-7310(02)76594-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Nakamoto S, Kaneda T, Inoue T, Matumoto T, Onoe M, Kitayama H, Oka H, Zhang Z, Otaki M, Oku H. Disseminated cholesterol embolism after coronary artery bypass grafting. J Card Surg 2001; 16:410-3. [PMID: 11885774 DOI: 10.1111/j.1540-8191.2001.tb00543.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Blue toe syndrome caused by cholesterol emboli is a relatively benign disease. However, disseminated cholesterol embolism is a life-threatening condition. We describe here the case of a 71-year-old female admitted because of anterior chest pain and intermittent claudication. Following cardiac catheterization, warfarin potassium was administered. However, the patient's toes soon darkened bilaterally, and BUN and creatinine levels increased from the normal value. Skin discoloration and renal failure were improved after stopping warfarin potassium administration. The patient underwent coronary artery bypass grafting and left femoropopliteal bypass. Cerebral infarction and renal failure occurred postoperatively due to disseminated cholesterol embolism. The patient died from renal failure on the 16th postoperative day without regaining consciousness following surgery. For high risk patients, interventional procedures to the ascending aorta must be avoided. When CABG cannot be avoided for coronary revascularization, off-pump bypass and use of arterial grafts are recommended.
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Affiliation(s)
- S Nakamoto
- Department of Cardiovascular Surgery, Kinki University School of Medicine, Osakasayama, Osaka, Japan
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46
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Henry M, Klonaris C, Henry I, Tzetanov K, Le Borgne E, Foliguet B, Hugel M. Protected renal stenting with the PercuSurge GuardWire device: a pilot study. J Endovasc Ther 2001; 8:227-37. [PMID: 11491256 DOI: 10.1177/152660280100800301] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To evaluate the feasibility and safety of renal artery angioplasty and stenting utilizing a distal protection device to reduce the risk of intraprocedural atheroembolism. METHODS Twenty-eight hypertensive patients (18 men; mean age 71.3 +/- 8.6 years, range 49-87) with atherosclerotic renal artery stenosis (4 bilateral) underwent angioplasty and stenting with distal protection in 32 renal arteries (29 ostial lesions). The lesion was crossed with a GuardWire temporary occlusion balloon, which was inflated to provide parenchymal protection. Generated debris was aspirated and analyzed. Blood pressure and serum creatinine levels were followed. RESULTS Immediate technical success was 100%. All lesions were stented, either directly (14 ostial lesions), after predilation (15 ostial lesions), or owing to suboptimal angioplasty (3 nonostial lesions). Visible debris was aspirated from all patients. Mean particle number and diameter were 98.1 +/- 60.0 per procedure (range 13-208) and 201.2 +/- 76.0 microm (range 38-6206), respectively. Mean renal artery occlusion time was 6.55 +/- 2.46 min (range 2.29-13.21). Mean follow-up was 6.7 +/- 2.9 months (range 2-17). Systolic and diastolic blood pressure declined from 167.0 +/- 15.2 and 103.0 +/- 12.0 mm Hg, respectively, to 154.7 +/- 12.3 and 93.2 +/- 6.8 mm Hg after the procedure. The mean creatinine level dropped from 1.34 +/- 0.35 mg/dL preprocedurally to 1.22 +/- 0.36 mg/dL at 24 hours and remained constant. At 6-month follow-up, renal function did not deteriorate in any patient, whereas 5 patients with baseline renal insufficiency improved after the procedure. CONCLUSIONS These preliminary results suggest the feasibility and safety of distal balloon occlusion during renal interventions to protect against atheroembolism. This technique's beneficial effects should be evaluated by randomized studies.
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Henry M, Klonaris C, Henry I, Tzetanov K, Borgne EL, Foliguet B, Hugel M. Protected Renal Stenting With the PercuSurge GuardWire Device:A Pilot Study. J Endovasc Ther 2001. [DOI: 10.1583/1545-1550(2001)008<0227:prswtp>2.0.co;2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Nakahama H, Sakaguchi K. Small dose oral corticosteroid treatment rapidly improved renal function in a patient with an acute aggravation of chronic renal failure due to cholesterol embolism. Nephrol Dial Transplant 2001; 16:872-3. [PMID: 11274298 DOI: 10.1093/ndt/16.4.872] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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49
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Espejo Marchante B, Torres de Rueda A, Gutiérrez Martínez E, Martínez Martínez A, Alcázar de la Ossa J, Usera G. Ateroembolismo de colesterol. HIPERTENSION Y RIESGO VASCULAR 2001. [DOI: 10.1016/s1889-1837(01)71148-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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50
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Ribera Pibernat M, Bigata Viscasillas X, Fuentes González M, Bielsa Marsol I, Ferrándiz Foraster C. Enfermedad por émbolos de colesterol: estudio de 16 casos. Rev Clin Esp 2000. [DOI: 10.1016/s0014-2565(00)70036-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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